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t <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-769 F PECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Quail Lakes Alexandria 8 5 Mile Slough) r m <br /> JOB ADDRESS ( 9 ) jr rCITY/ZIP Stockton 95206 m <br /> D <br /> CROSS STREET Alexandria PI APN 11206067 PARCEL SIZE 0.33 acres LAND USE APPLICATION# o <br /> A <br /> m <br /> OWNER NAME City of Stockton Municipal Utility Dept. Job#1016010 PHONE 209-937-8700 <br /> OWNER ADDRESS 2500 Navy Drive CITY/STATE/ZIP Stockton CA 95206 <br /> CONTRACTOR Farwest Corrosion Control PHONE 510-952-6256 <br /> CONTRACTOR ADDRESS 2223 Commerce Place CITYISTATElZIP Heyward CA 94545 <br /> SUBCONTRACTOR n/a PHONE n/a <br /> SUBCONTRACTOR ADDRESS n/a CITy/STATE/ZIP n/a <br /> LICENSE EC-57 EIC-611 [::]D-09 Other NUMBER 248232 EXPIRATION DATE 12-31-2019 <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392)E Arsenic(4393) <br /> INTENDED USE Domestic/Private r""'Trigation/Agricultural Ljndustrial Water Quality Monitoring 77 Soil Sampling/Characterization <br /> ri Public Water System <br /> If different Irom Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK V/ New Well - Replacement Well =Well Alteration/Modification ✓ Other Cathodic Pro ection <br /> O Monitoring Well(s) #of wells oil Boring(s) #of bonngs _ Geotechnical of bobngs <br /> -Out-Of-Service Well -Out-Of-Service Well Renewal = Cross-Connection Repair <br /> - New Pum - Pump Replacement -Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ✓DAud Rotary DAir Rotary -Auger -Cable Tool - Push Point ❑ Other <br /> Proposed Well Depth 45 ft Excavation in diameter - Open Bottom ravel Pack/Gravel Size in diameter <br /> -Conductor Casing n/a in diameter / Conductor Casing De th Na ft <br /> Well Casing Diameter L in Thickness/Gauge/ASTM Sched PVC Sch 80 S[eel - Plastic C Stainless Steel �ther <br /> i <br /> IF <br /> Grout Seal Depth 1J it QNeat Cement(94 Ib bag/5-10 gal water) =Sand Cement sack mix/7 gal water <br /> - <br /> Bentonite(26%solids) --Other <br /> Grout Placement Method)+ LI-umped -Free Fall -Other Tremmie -Retardant/Accelerator(name) <br /> PEDESTAL Installed By [DDriller - Pump Contractor L.Zj Other Mnnpp1 <br /> - Concrete Pedestal_-Dimensions:Width it Length ft Thick in -Christy Box -Stove Pipe <br /> PUMP - Submersible=Turbine -Other N/A HP N/A Pump Set NA It Standing Water Level N'A ft <br /> I HEREBY CERTIFY THAT I JdQVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH JHE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION WS. <br /> MI QIMU 48 R A 6 N TICE REQUIRED FOR SPECT NS PLEASE CALL(209)W-76,97 J <br /> -` V/1/114v/ "n /�/'' DATE /����•/ <br /> SIGNED TiT7T- <br /> S E E P L A N S F O R D E T A I L S <br /> T <br /> D <br /> c19 <br /> —————dill —11———— ——— 11 1, uNTY <br /> AL <br /> ENT <br /> %•' DEPARTMENT USE O LY <br /> Application Accepted By r� Date 1 Area Employee ID#S�t r'A' Irl-1�'��,/ <br /> Grout Inspection By - Date / SPECIAL Well Permit� /✓(, �(�/7 <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Ins coon By Dale Constructed ell DI <br /> pth <br /> COMMENTS e V �- w r r) SC L'( L✓ I✓i <br /> r�2 ' <br /> PE Sc Received ec mount Date Permit/ Invoice A Well IDA' ` " •�i <br /> Codes Ino B Remitted Service Request III,-43A-191- / <br /> 1511 3 <br /> IAIRt <br /> EHD 43-M rsv1 4114118 WELL/PUMP PERMIT <br />